Aims This research aimed to explore how supplementary prescribing in nursing and pharmacy was working in practice in England. Research was undertaken from to In the second report of the review recognised the potential benefits to patients of extending prescribing responsibilities to healthcare professionals other than doctors and dentists and the few district nurses and health visitors who were already qualified NMC In , the DH also published Making a Difference.
The document reaffirmed the government's intention to extend the roles of nurses, midwives and health visitors to make better use of their knowledge and skills, including making it easier for them to prescribe. While the recommendations outlined in the document applied to England, other countries in the UK subsequently adopted many of the principles it contained, in particular the extensions to the role of the nurse in relation to prescribing.
Among other things, it made the following proposals with regard to patient care. The service was to be:. The necessary extended training was to be available to any first-level registered nurse or registered midwife. Those POMs included some controlled drugs. In addition, independent prescribers could prescribe all items in the nurse prescribing list for District Nurses and Health Visitors.
In April , the Government enabled nurses and pharmacists to train to become supplementary prescribers. Section 63 of the Health and Social Care Act enabled the government to extend prescribing responsibilities to other health professions and to allow new types of prescribers by attaching conditions to their prescribing. Provisions in Northern Ireland NI can be found on the following web site: www. Nurses, pharmacists, physiotherapists, radiographers, podiatrists and optometrists can prescribe in partnership with a doctor or dentist.
Nurse and pharmacist supplementary prescribers are able to prescribe any medicine including controlled drugs and unlicensed medicines that are listed in an agreed CMP. All supplementary prescribers may prescribe for any medical condition, provided they do so under an agreed, patient-specific CMP. In October , the Committee on Safety of Medicines CSM considered responses to two previous consultations which examined options for the future of nurse prescribing along with the introduction of independent prescribing for pharmacists.
They recommended to Ministers that suitably trained and qualified nurses and pharmacists should be able to prescribe any licensed medicine for any medical condition within their competence. SP provides a new and robust legal framework for those situations where expert nurses already do, or could, advise their medical colleagues on appropriate choices of medicines, or where they currently obtain signatures on prescriptions for patients whom they have examined and assessed, but the doctor has not seen.
It frees nurses to combine the professionalism of expert practice with the responsibility of prescribing for patients with complex or long-terms needs. The outcome should benefit patients by reducing the number of appointments they require and providing a more seamless service, and should benefit professionals by enabling them to work together to make the best use of their skills and time. Department of Health: www.
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Provisions in Northern Ireland are a matter for relevant NI legislation. Amendments to the Prescription Only Medicines Order and NHS regulations allow supplementary prescribing by suitably trained nurses and pharmacists.
Supplementary prescribing is intended to provide patients with quicker and more efficient access to medicines, and to make the best use of the skills of trained nurses and pharmacists.
Over time, supplementary prescribing is also likely to reduce doctors' workloads, freeing up their time to concentrate on patients with more complicated conditions and more complex treatments. Time spent initially developing a simple Clinical Management Plan, should be time saved when the patient returns for review to the supplementary prescriber rather than the doctor. Comparison with independent nurse prescribing and with Patient Group Directions. Following training incorporated into their specialist practitioner programmes, District Nurse and Health Visitor independent prescribers can prescribe from the Nurse Prescribers' Formulary for District Nurses and Health Visitors: this comprises a limited list of medicines and a large number of dressings and appliances relevant to community nursing and health visiting practice.
This includes all Pharmacy and General Sales List medicines prescribable by GPs on the NHS, together with a list of specified Prescription Only Medicines to treat conditions in four broad therapeutic areas - minor illness, minor injury, health promotion and palliative care. Patient Group Directions are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment. The Department has always made it clear that the majority of clinical care should be provided on an individual, patient-specific basis.
Consequently the supply and administration of medicines under Patient Group Directions should be reserved for those situations where this offers an advantage for patient care without compromising patient safety , and where it is consistent with appropriate professional relationships and accountability. The independent prescriber must be a doctor or dentist.
It is for the independent prescriber to determine which patients may benefit from supplementary prescribing and the medicines that may be prescribed by the supplementary prescriber under the CMP. The independent and supplementary prescribers must agree how to maintain communication, and that communication must be maintained, while the supplementary prescriber is reviewing and prescribing for the patient They should ideally jointly carry out the formal clinical review at the agreed time - normally within a maximum of 12 months of the start of the CMP.
Periods longer than 12 months between joint clinical reviews or reviews by the independent prescriber may occasionally be acceptable in the CMP where the patient's condition has been shown to be stable and deterioration of the condition is not to be expected during a period longer than 12 months. The appropriateness of such a longer period between joint or independent prescriber clinical reviews is the responsibility of the independent prescriber though it must be agreed with the supplementary prescriber.
If a joint clinical review is not possible, the outcome of the clinical review by the independent prescriber needs to be discussed with the supplementary prescriber, who must agree continuation of, or changes to, the CMP. The independent prescriber should be the clinician responsible for the individual's care at the time that supplementary prescribing is to start. Supplementary prescribing partnerships involving more than one independent prescriber e. Supplementary prescribing may only take place after a specified point in the individual patient episode, i.
The independent prescriber is responsible for the diagnosis and setting the parameters of the CMP, although they need not personally draw it up. The supplementary prescriber has discretion in the choice of dosage, frequency, product and other variables in relation to medicines only within the limits specified by the CMP.
The Plan may include reference to recognised and authoritative clinical guidelines and guidance local or national , whether written or electronic, as an alternative to listing medicines individually. Any guidelines referred to should be readily accessible to the supplementary prescriber when managing the patient's care. Supplementary prescribing must be supported by a regular clinical review of the patient's progress by the assessing clinician the independent prescriber , at pre-determined intervals appropriate to the patient's condition and the medicines to be prescribed.
The intervals should normally be no longer than one year and much less than this if antibiotics are to be included in the CMP. However, as stated in paragraph 15 above, longer periods, during which the patient continues to be reviewed by the supplementary prescriber, may be appropriate when the patient's condition is stable and is expected to continue to be stable.
The independent prescriber and the supplementary prescriber must share access to, consult, keep up to date, and use, the same common patient record to ensure patient safety. The key to safe and effective supplementary prescribing is the relationship between the individual independent prescriber and the individual supplementary prescriber. These two professionals should:. Share access to the same local or national guidelines or protocols, where these are referred to in the CMP. The initial clinical assessment of the patient, the formulation of the diagnosis and determining the scope of the CMP.
Reaching an agreement with the supplementary prescriber about the limits of their responsibility for prescribing and review - which should be set out in the CMP. Carrying out a review of patient's progress at appropriate intervals, depending on the nature and stability of a patient's condition. Reporting adverse incidents within local risk management or clinical governance schemes. Prescribing for the patient in accordance with the CMP. Altering the medicines prescribed, within the limits set out in the CMP, if monitoring of the patient's progress indicates that this is clinically appropriate.
Monitoring and assessing the patient's progress as appropriate to the patient's condition and the medicines prescribed. Working at all times within their clinical competence and their professional Code of Conduct, and consulting the independent prescriber as necessary.
Accepting professional accountability and clinical responsibility for their prescribing practice. Passing prescribing responsibility back to the independent prescriber, if the agreed clinical reviews are not carried out within the specified interval see paras 15 and 17 above or if they feel that the patient's condition no longer falls within their competence.
Recording prescribing and monitoring activity contemporaneously in the shared patient record or as soon as possible - ideally within 24 to 48 hours.
Independent and supplementary prescribers must be willing and able to work together and to assume the specific responsibilities listed above. Independent and supplementary prescribers may work in more than one prescribing partnership, providing that in each case they work as described above. Before starting to undertake supplementary prescribing, the supplementary prescriber will need to:.
Successfully complete the specified training and preparation for supplementary prescribing, including all assessments and the period of learning in practice. Ensure that their supplementary prescribing competency is recorded on the relevant Nursing and Midwifery Council professional register. Agree with the independent prescriber to enter into a prescribing partnership with them, and record that agreement in the patient's record.
Reach agreement with their employer that supplementary prescribing should form part of their professional responsibilities. There are no legal restrictions on the clinical conditions that may be dealt with by a supplementary prescriber. Supplementary prescribing is primarily intended for use in managing specific chronic medical conditions or health needs affecting the patient.
However, acute episodes occurring within chronic conditions may be included in these arrangements, provided they are included in the CMP. Wherever it is proposed to manage a patient's condition through the use of supplementary prescribing, the principle underlying the concept of supplementary prescribing i. The agreement of the patient to the prescribing partnership should be recorded in the CMP and patient record. Without such agreement, supplementary prescribing may not proceed.
A nurse supplementary prescriber must be a 1st level Registered Nurse or Registered Midwife whose name in each case is held on the NMC professional register, with an annotation signifying that the nurse has successfully completed an approved programme of preparation for supplementary prescribing. The selection of nurses who will receive training in prescribing is a matter for local decision, in the light of potential benefits for patients and local NHS needs. All individuals selected for prescribing training must have the opportunity to prescribe in the post they will occupy on completion of training.
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